Advocacy

The ACP Advocate Blog

by Bob Doherty

Tuesday, July 24, 2012

Facts challenge physicians’ views on Medicare spending

If you ask doctors about Medicare spending growth, most will tell you that Medicare payments to doctors haven’t increased in a decade, and that doctors are turning away Medicare patients in droves. But they would be mistaken on both counts.

An authoritative compilation of current data from the Medicare Payment Advisory Commission shows what is really happening with Medicare physician spending:

Medicare spending per beneficiary on physicians’ fee schedule services steadily increased from 2001 to 2011. In 2001, Medicare spent $1,374 per enrolled senior, and $1,160 per disabled enrollee; ten years later, it was $2,181 and $1,883 respectively.

Volume growth is the reason Medicare is spending more. From 2000 through 2010, Medicare payment updates increased by only 8 percent (due principally to the Medicare SGR formula), compared to a 22 percent increase in physicians’ costs of delivering care as measured by the Medicare Economic Index. But overall spending per beneficiary on Medicare physician fee schedule services increased by 63.7 percent during the same ten-year period. How could that be? Because the volume of services—the number of tests, visits and procedures ordered by physicians on their Medicare patient’s behalf—increased at a much faster rate, pushing overall spending per patient upward, even as payment rates didn’t keep up with inflation.

More diagnostic testing and procedures are the main culprits. From 2000 through 2010, the volume of diagnostic tests increased by 89 percent, the volume of imaging by 81 percent, and the volume of procedures other than major surgery by 65 percent. The volume of major surgical procedures, and evaluation and management services (office, nursing home, home, hospital, and other visits), increased at a much lower rate of 35 percent.

Because of higher volume, physicians’ Medicare revenue has increased. Even though the SGR has kept payment updates below inflation, MedPAC reports that “growth in the volume of services contributed more to the rapid increase in Medicare spending payment rate increases ... both factors—updates and volume growth—combine to increase physician revenues.”

Medicare patients have better access to physicians than the privately insured. In 2011, 74 percent of Medicare beneficiaries, and 71 percent of privately insured patients, reported “never” having to wait longer than they wanted to get an appointment for routine care. Medicare beneficiaries also reported more timely appointments for injury and illnesses. Only 6 percent of Medicare enrollees said they were looking for new primary care physician, compared to 7 percent of the privately insured, suggesting that “most people are either satisfied with current physician or did not have to look for one.”

A larger, but still comparatively small, number of Medicare patients reported trouble finding a primary care physician. Of the 6 percent of Medicare beneficiaries who were looking for a new primary care physician in 2011, 35 percent reported having trouble finding one—23 percent of them reporting their problem as “big” plus 16 pecent reporting their problem as “small.” The Commission notes that “although this number amounts to about 2 percent of to the total Medicare population reporting problems, the Commission is concerned about the continuing trend of greater access problems for primary care.”

I suspect that the first reaction of many physicians to these data will to insist that MedPAC must be wrong, that they know from their own experiences that Medicare payments haven’t kept pace with their costs and that they know of many doctors who are turning away Medicare patients. And they may be right, in the sense that their own personal experiences may not match the data on national trends and the cumulative impacts of spending growth per patient and physician.

But just as good physicians don’t ignore or dismiss clinical data that challenges their own perceptions and experiences, the medical profession shouldn’t ignore the data on what is really going on with Medicare spending and access. The fact is that spending on physician services in the aggregate has grown rapidly, even with the SGR-imposed limits on payment updates, and the culprits are more testing, imaging, and procedures being ordered for each beneficiary. And despite some evidence of greater access problems for primary care, most Medicare patients—so far—are not having major problems getting appointments or finding a primary care physician or a specialist.

Armed with these data, Congress isn’t likely to spend hundreds of billions to just eliminate the SGR, absent a plan to control the volume of services. As MedPAC notes:“Volume growth increases Medicare spending, squeezing other priorities in the federal budget, and requiring taxpayers and beneficiaries to contribute more to the Medicare program . . . They are largely responsible for the negative updates required by the SGR formula. Rapid volume growth may be a sign that some services in the physician fee schedule are mispriced.”

Last week, ACP’s President David Bronson, MD, FACP, told the House Energy and Commerce Committee about innovative, physician-led initiatives that could help solve the Medicare SGR problem, and today, he testified before the House Ways and Means on how ACP proposes “to transition from a fundamentally broken physician payment system to one that is based on the value of services to patients, building on physician-led initiatives to improve outcomes and lower costs.”

Ignoring the facts will not heal a broken payment system, but offering the medical profession’s own diagnosis and treatment plan informed by the evidence just might help.

Today’s question: what is your reaction to the data on Medicare spending on physician services?

23 Comments
:

It sounds like the data supports physician's views that the medicare payments have not kept pace with costs of doing business (8% over a decade versus 22% increase in costs). If you have to see more patients per unit of time to keep afloat you'll order more expensive studies and procedures in lieu of lengthy evaluation and education sessions.

I can't speak for the national medicare access problem, but my wife had to seek a new physician when her old one quit accepting medicare.

The SGR is flawed. The most difficult aspect of patient care is managing complicated patients with multiple comorbidities on multiple medications. This takes a lot of thought and time and should be adequately compensated.

The point has been made in a number of different ways that we have the money in our system to cover even the medical needs of the uninsured. The problem is distribution.

I feel it is important to remember that we have now reached the tipping point in terms of hospital or corporate owned practices. This will impact the way doctor’s practice as they meet the standards of number of visits per day, and additional testing of their employers.

We can also see from this link that doctors can find ways to financially capitalize on even a closed system:

For those of us who only do cognitive services, volume is something very difficult to deal with. On the contrary, I have had to extend patient appointment times rather than shorten them. I feel comforted to know that my services have not lead to the volume growth in Medicare spending. I see about 30% less patients now than 10 years ago. By spending more time with patients, I have not relied heavily on diagnostic testing. You just can’t beat a good history and physical exam and the time to mull it over. I do see many other physicians doing procedures more rapidly and reaping the benefit of volume.

The impression that reimbursement has remained flat (8% increase in 10 years seems flat to me considering inflation and practice cost increases) is exacerbated by the increasing tasks that are required of us primary care docs over the same time period. The number of prior authorizations for medications explodes once Medicare part D went into effect.

As far as primary care goes, the most critical group who will need access to primary care is the 20% who consume 80% of health care dollar. As the cognitive based physicians wither on the vine, that group of people will be a cash cow for those who want to profit from the system.

1) What was the percentage increase in medicare rolls during this time?

2) What was the average age of each enrolee in 2001 vs 2011?

3) What portion of the billings were by non-physician providers ie ANPs etc. in 2001 vs 2011?

4) What percentage of Primary care visits are to ANPs/PAs now vs Doctors and how does that compare to 2001? Is that part of the new cost paradigm ie more referrals and therefore more tests and procedures?

5) Does access to primary care for Medicare patients increasingly mean access to such providers now vs 2001? Are patients content with such access?

7) When CMS is rolling out its endless unproven mandates PQRI, EHRs, e-prescribing, forms etc, is the unreimbursed work component fo these included in the reimbursement?

8) What is the role of guidelines and new medicare benefits such as the annual medicare physical, along with new technologies on one hand and of our current tort system on the other in driving this volume?

9) What percentage of these tests and procedures were accounted for by the increased role of Corporate america in the practice of medicine? More investments, more management pressure, more physician employment, more tests in Hospital owned entities needed for better ROI?

10) No Medpac is right Bob. It asks all the questions it should from the vantage point of the payers. The more pertinent question Bob is where are you and ACP with the pertinent questions from a practicing Physicians vantage point? Why are you cheerleading their perspective and ignoring that of those you purportedly represent?

You can bombard us manufactured data, Bob, but that does not hide the truth...that price-fixing hurts quality of care and results in higher volume, lower quality of care. I am one of the physicians that has stopped accepting new Medicare patients since Jan 2010. In fact, I am hoping that the full level of SGR cuts are enacted come January 2013, so I can conscientiously opt out of Medicare.

The data aren't manufactured, folks. They are the actual amount of money that Medicare is spending per beneficiary and how it has changed over the past ten years, and the reasons for the increase. Not all physicians, of course, have increased volume, not all physicians have seen increases in revenue, not all Medicare patients are getting more tests and procedures, but in the aggregate, Medicare is spending more PER BENEFICIARY than it did ten years ago and that increases in use of imaging and other lab tests are the principal culprits.

Effective advocay for internists and their patients requires that we understand what is going on with health care spending and be prepared to explain why such increased spending per patient is a good thing, but to the extent that at least some of the increased spending is for marginal, ineffecttive and evern harmful care, to recommend our own solutions based on what is best for patients. Or we can just ignore the data and let the politicians draw their own conclusions and determine their own remedies (usually involving across the board pay cuts, more preauthorization requirements, more denials of payment)--you choose. I am proud that ACP's advocacy is evidence based and patient-centered.

Imaging has also increased in care provided by private sector health plans.

Assuming for a moment that the data aren't manufactured, it is still a problem that the ACP is willing to accept price-fixing as a legitimate solution. Unless you understand and believe this fundamental fact that utilization of services depends directly on whether the provider and receiver of service have any stake in setting the price of the service. Currently no such stake exists. So this will not change even if you show "evidence", which really is trying to catch a plume of smoke and frame it, if you understand what I mean.

I think it has been widely reported that the trend in medical practice is toward more testing and less time with patient contacts. There is also a feeling among many physicians that over testing can be used to placate demanding patients or decrease liability risks. So it is hardly a surprise that Medicare physician-driven costs have increased along the same lines.

And what is driving this cost increase? Misguided government policies that reward technology over cognitive patient care, dismiss liability fears as insignificant, and reward providers for "treating the chart" instead of the patient, squandering limited physician time on mindless paperwork and data entry.

I also found Chart 1-9 (page 11 in the MPAC report) interesting. Physician fee based payments have decreased, while Managed Care takes almost a quarter of the Medicare expenditures. In 2003, Congress passed the Medicare Modernization Act (MMA), predicting savings for taxpayers and better health care for beneficiaries. MMA pumped substantial new funding into Medicare’s private plans and increased the windfall payments that these plans receive, paid 12% more per patient than traditional Medicare, with no cost savings. Another foolish and wasteful government program to reward insurers and cheat patients and their doctors.

As long as ACP advocacy continues to accept blame for these trends as physician caused, and cover for the real villain, politicians will surely draw their own conclusions.

Mr. Doherty and the findings of MEDPAC are correct. The volume of cognitive services may not have changed significantly, However, I am sure that there is no community where procedural services have not increased.Why?Answers will include a sicker patient, advances in diagnostic testing and the like, but, we must admit that we tolerate unreasonable excesses of a few of our colleagues because of an unspoken code of silence.These excesses are fraudulent abuses of clinical privilege, they are no different from other financial frauds perpetrated and reported daily.If the reader were to evidence a neighbor's home being burglarized would it be immoral not to report the crime.Abuse of public health funds are tolerated and rarely reported.Physicians' heal yourselves.

With representation like this, is it any wonder our profession continues to witness a deterioration in practice conditions?The sheer arrogance of ACP leadership in its certitude of the direction they are taking us is astonishing. They are lightening quick to point out physician centric issues while lazily ignoring much more significant issues around other elements of the health care system. When pointed toward some of those issues, there is deafening silence.You guys in historical medical organisations are leaving doctors little option but to organise into a different representative groups. You ignore decreasing membership levels, artificially inflate your roles with free medical student memberships etc. Dismiss discontent with your big gov't role advocacy amongst your membership and continue to build your revenue streams away from membership dues and towards contributions from those you actually represent in corporate america and big gov't. I am glad i have left the ACP because im my opinion you work against both my interest and that of my patients. Whether you do that out of sheerly being misguided/detached or corrupt is immaterial.

I allowed PCP's last comment to be published because I encourage debate among readers of this blog. However, I will not allow commentary in the future that impugns the motivations and integrity of others by accusing them of being corrupt. There is a line of civil discourse that often is ignored in the social media world but it cheapens debate. So readers, please stick to the issues, assume that others who disagree with you are acting in good faith but just see things differently than you. I start with the premise that those of you who are critical of ACP are acting out of principle and concern for patients and the public and would expect the same. As has been the editorial policy of this blog from day one, I reserve the right to not post comments that attack the motives and integrity of others. There are other blogs available for flaming people you dungarees with but this is not one

I would like to pull a couple of excerpts from earlier postings in this blog.

BDoherty, wrote:

"but to the extent that at least some of the increased spending is for marginal, ineffecttive and evern harmful care"

Ashok Daftary wrote:

"we must admit that we tolerate unreasonable excesses of a few of our colleagues because of an unspoken code of silence.These excesses are fraudulent abuses of clinical privilege, they are no different from other financial frauds perpetrated and reported daily"

Then BDoherty writes:

"However, I will not allow commentary in the future that impugns the motivations and integrity of others by accusing them of being corrupt."

Why is it acceptable to second guess practicing physicians about "ineffective and harmful care" and that we engage in the "fradulent abuse of clinical privilege" or that we "take out childrens tonsils unnecessarily"

Is that not "impugning the motivations and integrity of others"?

Look Bob this is your blog and you are free to censor or remove any comment you see fit. Clearly some of us believe that the Doctor Patient relationship needs less not more interference. If cost issues emerge as a barrier to getting the needed test/remedy etc. then that too ought to be discussed within the context of that relationship and options/costs/risks/benefits etc explored. That is the best way to ration care in my view and that would also work to address the issue of cost, I also feel it will help restore the role of a solid PCP in directing patient care. That can only happen in the setting of a free market with HSAs etc.Unfortunately we will not agree on this. What is troublesome is the double standard employed. The irony is that this interaction is a microcosm of the larger polarized political debate. Whether leaders are leading us to this gridlock as a nation or representing us in this deadlock is something I am not clear about, I suspect it is a bit of both. Either way, it feels like we as a nation are at the crossroads.

PCP, there is a difference. Stating that wasteful, inefficient and marginal care is being provided does not question the integrity of any particular physician, it simply states what we all know is true, that much of the care being provided in the United States is ineffective or unnecessary. Why is a different matter--patient demand, defensive medicine,a payment system that rewards procedures over cognitive services, lack of price transparency and competition--all are implicated, and none of those reasons impugn the integrity of any individual physician or even the profession as a whole. But a statement that ACP's leadership is misguided or "corrupt"--it is the latter where I draw the line, because I know the leadership of ACP personally, and they are without exception committed, honest, and dedicated physician-leaders who are doing what they believe is best for the doctor-patient relationship. Yes, this is my blog, and I have err on the side of allowing provocative commentary (how many association sponsored blogs, by the way, post comments that encourage its members to quit the organization! Yet I allow that, because it is a perspective that I think should be heard). But I will draw the line in the sand against any future commentary that impugns the integrity of specific persons. That isn't censorship, by the way, since censorship involves government control of free speech. It simply is my standards of the kind of commentary that I think contributes to thoughtful and reasoned debate versus the personal invective that characterizes many other blogs.

Bob, your thought process disturbs me a lot. It is clear to me that while you encourage various views, you are really not debating in a true sense. In a real debate, one must be open to accept the side's principles.

What PCP is saying is that you can label any of the comments as offensive because it is your blog. But as members or former members of ACP, we find what the leadership is doing equally offensive. In fact, actions are far more destructive than mere words, and that's what the ACP leadership is doing to many of its members. Only time will tell, but most of us may not be around to say "I told you so".

I wish that Bob had not made any comment about PCP's post.PCP does come close to impugning doctors who are acting in good faith.But Bob allowed for the argument to take a tangential turn -- and moved away from the substance.

Can we return to that.

Fox News does this all the time. When it is obvious they are losing a debate on the substance, they bring up an anecdote and then inflame, inflame, inflame.

In my view there are a few issues of substance here:

-- Medicare as a budget item is increasing. Medicare part B in particular has gone up, which is why it has been a target. Some of that is shifting from Medicare part A.It is price controlled which is a bad decision.Price controls have allowed for the strategy of increasing by volume, which works well if you read films all day or if you just have to squeeze in another cataract surgery,....There is a time limit for Primary Care Physicians, and we are the ones getting hit the worst by all of the pay for performance schemes.

We need to focus on that.

We need to focus on how physicians will be paid in the future.

It is right for ACP to lead on this issue.It is wrong for ACP to argue in front of Medicare or any other large payer group that we want to bring back fee for service medicine without the price controls.It is wrong because it simply isn't on anyone's radar.We will be asking our organization to become marginal to the point of being a laughing stock.

ACP has to pay attention to its members.It should encourage physicians to work in organizations (contractual or by employee relationship) where they can be successful and be in the best position to help our patients.ACP should first and foremost be an advocate for our patients.That is how we gain political advantage.That is how we gain esteem in the public arena.

If we argue for practice models that will never again thrive, then we will stop being an important organization.

Again, I am glad we have this forum, as these diametrically opposing views need to be heard. I certainly don’t agree with Harrison and his assumption we must forego any defense of the basic principles of fee for service. Clearly, his view has a following throughout organized medicine, however.

Regarding the Medicare numbers, I wish there was a little more meat there. The outpatient visits at hospitals versus those in offices would be especially interesting to parse. The markedly divergent curves between basic E and M versus procedures and tests needs emphasis. It may indeed reflect the greater needs of modern patients. As well, the debundling efforts that forced ordering individual profiles is certainly relevant to this period. This would inflate the number of tests ordered, even when actual testing is unchanged. As seems to be a theme, rules designed to hassle physicians do not streamline care and are interpreted to our disadvantage.

I would also note the doubling in the last year (from 11 to 23 %) in the rate of marked difficulty finding a new primary care physician in Medicare. Ignore this one at your own peril. This is real. This is not a threat. When you have to pay the bills and meet the salaries, reality is hard to ignore.

It is clear that the sentiment of PCP, ryanjo, myself and others is that of the independent internist trying to defend the point of view of old fashioned medicine. Having that perspective perpetually challenged by the thrust of academic medicine, both sides of the aisle in Washington, and our professional leadership is difficult. Some degree of emotional reaction is understandable. The reality of what new bureaucratic realities bring to bear on independence cannot be denied. An analysis of intent is always precarious, but it cannot be denied that intentional versus unintentional would be one accurate way to delineate.

It would be nice if our voices were heeded, and our underlying perspective gained traction, before management of physicians becomes more entrenched than being one. Call me farfetched.

Harrison, you are completely mistaken. Fee for service has never been the problem, and should never be. Just like any other professional - lawyers, accountants, investment bankers, architects, etc. - doctors have the right to charge (and be paid) a fee for their service. the problem is 3rd party, price-fixed fee for service, where the patient has no say in what a service should cost. If we truly want to empower the patient, let the patient decide what value he/she assigns to a particular service, not the 3rd party. I will salute the ACP leadership, if it has the courage to come out and say this publicly.

I am more than happy to stipulate that fee for service would have a very good chance of working if the patient were paying the fee.

But I think that everyone has to agree that a fee for service system where the person receiving the service pays little or nothing for the service directly cannot work.And it especially won't work if the person receiving the service pays something indirectly regardless of whether they receive the service, because then they will feel they are entitled to unlimited services and the provider of the service will feel obliged to charge for the feeling that they are really really in demand.When in fact they might not be.

And so I would ask that those arguing for traditional fee for service concede that doctors would be paid a lot less if the patients were paying directly.

And also please concede that there would be tremendous problems with access to care because of inability to afford care.

And also concede that if this had been in place since the 1960's we would not have had the explosion of medical technology innovations that we have seen because there would be no market to develop them into.

Harrison, you are completely misinformed about the dynamics of health care. Perhaps you have not met with or spoken to physicians who actually practice 1st party FFS medicine.

The fact is that we would actually collect significantly more in a direct pay FFS model as compared to what Medicare and private 3rd party payers pay. There would be less utilization of services, limited to what the patient and doctor mutually agree is truly necessary.

Access to care would actually be vastly improved without 3rd party...as evidenced in my own practice over the past 3 years. People with no insurance or those who pay cash get to see me faster and more regularly than Medicare/medicaid, and certain other private 3rd parties.

Innovation actually flourishes when 3rd party payment is not involved. Just take lasik surgery for example. In my own practice, we can apply various innovative methods of managing chronic disease in direct pay model, where we cannot do that with 3rd party payers because they simply do not recognize the benefit of innovation.

I don't want to be lumped in with those who call for a total free market with no third party coverage. The issue is: do we constrain costs via behavior modification primarily (financial incentives and disincentives via managed care gimics and bureaucratic entanglements), or do engage in the imperfect process of price regulation (maybe defined by a level playing field with fair rules, independence, and gradual adjustments) Third parties have a role, but we have allowed them to become for profit behomeths. We have also seen the counter-measures of similar entities on the provider side. I think a corrected SGR is a hell of a lot better than hiring a bunch of administrators and non-physicians to pick up the slack (essentially the argument of Ezekial Emmanuel and ACA advocates that I shut up and adjust to the "new" reality; ACO's are different because we have "metrics").

Look at the GAO report today. State budget directors are being forced to increase budgets for the Medicaid ACA roll-in. This despite the federal government picking up the tab. This means we are losing money as we get people insurance in a system that is already bankrupting states. Wow, we see these costs and blame insufficient bureaucracy. That is a shame.

As to the innovation question, the Hatch-Waxman era includes $500/year tetracyclines, $4000/yr type 2 diabetes drugs, biologics, and a generic system that is over-complicated, redundant, and taking advantage of their situation and increasing prices. All this waste has stymied innovation by perverting focus and resources to me-too drugs, billion-dollar babies, and playing the drug cycle. Long-term thinking has been punished. Technologies come and their prices never retreat (glucose strips at 70 cents, cards and ortho stuff, vaccines). A little price regulation will keep winners profitable without stymiing better approaches for "true" needs.

Here's a contrarian comment. Fix the SGR by increasing fees for cognitive specialties, cutting the schedule on ancillaries, and adding pharmaceuticals. Put a halt to all the bureaucratic inititiatives. Mandate an insurance landscape with non-profit, state regulated, insurance companies(reform ERISA, minimize federal dictates, let states have teeth to stabilize the private industry). Let Medicaid copy Medicare success, let the private sector grow (in sync with health care), and shrink the entitlements without cutting the throats of physicians.

I agree with Arvind that skeptics of a true FFS system, truly do not understand their marketability and demand for their services. With a widespread HSA, people would actually seek out general internists in place of either NPs or Specialists. Only in a price setting bureaucracy like medicare can ANPs demand shamelessly that they get pay parity with general internists, would someone paying from his/her HSA pay 85% see a ANP or pay the full amount and demand that they see the Internist for most issues? I do not know about what will happen to my income, I suspect it might go up, but maybe it will go down. Maybe then I don't turn over my inpatients to Hospitalists, maybe I invest in other value added services and refer less, maybe I do something else, at the very least it will change patients and the entitlement mindset.I think it will also make doctors free to practice medicine and not for a bureaucracy. It will make medicine truly patient centered, instrad of phony patient centered ie as dictated by a bureaucracy. The doctor patient relationship will be primary again. A lot will happen that will shock the skeptics, if only we have the courage to try to be free and not conform as Harrison suggests and the ACP advocates. To me even if my income were to decline, such a system restores a base from which our profession can rebuild what it has lost. Innovation is not lost if we change the way we finance our health care, I think we innovate in a different way. Technology is great and all, but if there is something that we have learnt over the past 40 yrs, technology is not all there is to great health care. It is precisely this idiocy that caused us to devalue primary care. A solid H&P is as distant from a technological innovation as it gets, yet we all know, if you know how to listen to a patient and know what questions to ask, you can be a better doctor. So innovation would evolve to cost effective innovation as the patients would demand that. Instead of the me too innovations that are all to frequent nowadays. So Harrison, you need to rethink that aspect of your rationale for a greater gov't role. As to your assertion about issues with access. Physicians have always been socially responsible and provided charitable care, the significant difference is 40 yrs ago doctors were frequently thanked for it, nowadays many of those recieving charity care appear to be more demanding and litigenous than their paying counterparts. As clearly evident from the blog owner's most recent blog. The ACP has apparently chosen their positions quite definitively. The tone of the entry, speaks about the celebratory role the NHS had in the olympic opening ceremony, the apparently unfounded skepticism of a scottish physician decades ago is mentioned. If only these folks took the time to speak with physicians practicing in the trenches of the NHS bureaucracy, looked at the downside, the low morale of staff etc. That the medical profession went on strike there for the first time in over 30yrs etc. Such is the ideological slant, that that system is apparently deemed ideal and nothing else matters. That it is celebrated at the London Olympics is sufficient evidence of it. That it is playing a large role in their fiscal problems is besides the issue. Reading about the clear ideological slant of the ACP, it remains a puzzle to us mere mortals, how this country has been so successful in various endeavours including health care without universal coverage being mandated.I supect that if we keep this up for another couple of decades, that as in much of the developing world, we too will get to the point where, on paper health care is free, just try getting it. Sadly it will take such destruction, before once again private FFS will emerge as the option and the purveyors of universal health care will come up with the latest excuse as to why it will be different this time.

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